Quality Account 2024/2025

Quality Account 2024/2025 www.thameshospice.org.uk

Part one Statements

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Statement from the Chief Executive

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About us

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Statement from the Chair of the Patient Care and Quality Committee and clincial leads

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Part two Review of quality performance 2024/2025

10

Thames Hospice facts and figures

12

Additional quality indicators

17

Patient safety summary

19

Significant audits

20

Part three Update on last year’s pledges

26

Part four Priorities for 2025/2026

28

Part five Statements of assurance from the Thames Hospice Board

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Paramedic Lewis visiting a patient at home

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Quality Account 2024/2025 | Thames Hospice

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We welcome your feedback

Part one

Statement from the

Your views on how we are doing are very important to us.

If you would like to pass on a message to any of our teams or suggest ways that we can improve our services, please use our online form at www.thameshospice.org.uk/get-in-touch or email intouch@thameshospice.org.uk If you would prefer to speak to someone in person, please contact our Director of Nursing Loren Broughton on 01753 842121.

Chief Executive Welcome to the Thames Hospice Quality Account 2024/2025. This publication is an important part of our accountability to the many individuals and groups with a stake in the work of Thames Hospice.

We are delighted to provide you with this summary of the quality initiatives that we have undertaken throughout the financial year, and to give you a high-level overview of some of our plans for the future. You are important to us, and we know you want to be assured of our attention to the quality of our services and our efforts to continuously improve wherever we can.

I was appointed Chief Executive of Thames Hospice in December 2024 and bring a wealth of clinical and strategic leadership experience to the charity. Before joining, I was Deputy Chief Executive and Chief Medical Officer of the Buckinghamshire, Oxfordshire, and Berkshire West Integrated Care Board (BOB ICB), and responsible for shaping healthcare services across the three counties.

Alongside my role at the Hospice, I continue to practice as a Consultant in Emergency Medicine at the Royal Berkshire NHS Foundation Trust.

My connection to hospice care is deeply personal. Having lost both my parents to cancer, I experienced first-hand the profound impact of hospice services. When I reflect on this time, I recognise that support from the local hospice allowed me to stop being a doctor to my father, and allowed me to ‘just’ be his daughter and make precious memories together.

Dr Rachael de Caux Chief Executive

Our vision is Quality of life to the end of life, for everyone.

However, there is increasing demand for our services, driven by an ageing population with more complex diagnoses, and an urgent need to do more to reach parts of our community who have not had access to our care. We have ambitious plans and priorities for the next three years to meet the challenges ahead. Our priorities include a focus on delivering the best quality of care to support patients and families and improving equity of access to our services. We are committed to ensuring that we are a place of hope and are dedicated to providing care and support to all those who need us today and for generations to come.

We have continued to focus our efforts on increasing support for people being cared for in the wider health and social care system. Our Inpatient Services ran at 84% occupancy over the year, and our Hospice at Home provision has again seen increased activity, with our Virtual Ward enabling us to care for more acutely unwell people in their own homes, rather than them being admitted to hospital or the Hospice. Once again, our patient satisfaction results have been exceptional, and you will find a few of the many accolades we received this year on page 18.

A top priority for the Clinical Team is always patient safety. We have continued to focus on identifying and earlier reporting of pressure ulcer changes in a patient’s pathway, as well as mitigating the risk of patient falls. We report and learn from any medication errors across all our services.

We continue to engage in constructive dialogue with our Commissioners to help to shape and fund our direct clinical care, including negotiating new contractual arrangements with our NHS partners to secure a fair deal for future years.

We work with colleagues across the local health and adult social care sector, to support the delivery of Frimley and BOB ICB’s palliative and end–of-life care priorities.

Thank you for taking the time to read our 2024/2025 Quality Account. We hope it gives you greater insight into our work and ambitions. To the best of my knowledge it is an accurate and fair representation of the quality of services that Thames Hospice provides.

Our concept of ‘Care with Agility’ is significantly improving the co-ordination and integration of our services with our wider healthcare partners. There have been significant reductions in waiting times for admission to our services, and our patients have a far clearer expectation of what we offer to support them and their loved ones.

Scan here to read our 2024-2027 strategy Visit thameshospice.org.uk/strategy

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About us

Our services

We are immensely proud of all that we have achieved since we were founded in 1987, providing specialist palliative and end-of-life care and support for our community across East Berkshire and South Buckinghamshire.

Referrals to our four key services are centrally co-ordinated by our Single Point of Access team and delivered by our multi-disciplinary colleagues, who work closely together to give our patients dignity, comfort and the best possible quality of life in their preferred place of care.

Today we serve a population of approximately 500,000 people and employ more than 360 staff who, with the support of over 1,000 volunteers, deliver care to thousands of people each year.

Whether in the Hospice or at home, our care, provided free of charge to patients and their loved ones, is tailored to meet their physical, psychological and spiritual needs. Our services are only possible thanks to the generosity of our community. Our supporters help us in many ways by donating, fundraising, volunteering, as well as shopping in our charity stores and so much more.

We need to raise

Find out more about how you can get involved at www.thameshospice. org.uk/supportus 6

£39,000

every day to continue delivering our vital care.

Occupational Therapists

at

i en

Pastoral Care Workers

Inp at ie t s a n d f a mi

lie

s

Single Point of Access Team Referrals, 24/7 Telephone Advice Line, Admissions & Discharges

P en ast t S o ra l up p or t

u e O vi c i r p Hos Se

Lymphoedema Specialists

Healthcare Assistants

Counsellors

t ce p a t s ie n t

Consultants

P

Pharmacists

Chaplain

e om H at

g, li n s el e m Co u n r e av e and B

Hospice Outpatient Services help people diagnosed with a life-limiting condition remain independent by supporting them through tailored programmes of wellbeing and therapeutic care within our Paul Bevan Wellbeing Centre at the Hospice. We also offer early care planning to help anticipate and achieve patients’ future care needs. Our provision includes structured outpatient programmes, lymphoedema services, physiotherapy and complementary therapy.

Paramedics

Ho sp ice

a re a t

Ou rc at ch

n

Hospice at Home Services are provided to people in their own homes, who need specialist palliative and end-of-life care. Our community care is delivered in partnership with GPs, District Nurses and other healthcare professionals.

Services include proactive and responsive clinical support, consultant-led care on our Virtual Ward and end-of-life domiciliary care.

Physiotherapists

Doctors

ces rvi Se nt

m e

Inpatient Services are delivered in our Inpatient Centre at the Hospice for patients who need specialist palliative and end-of-life care.

Clinical Therapists

Complementary Therapists Clinical Administration

Nurses

Counselling, Pastoral and Bereavement Services offer psychological, emotional and spiritual support for patients and families up to and following bereavement. This includes counselling for children and young people. We also support essential outreach work for underrepresented groups of patients.

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Statement from the Chair of the Patient Care and Quality Committee and our clinical leads A key focus in 2024/2025 has been the progressive growth of our community services with an expansion into the South Buckinghamshire Primary Care Network (PCN) to provide proactive caseload management alongside our existing acute response services.

Dr Nick Dando Medical Director and Deputy CEO

We have been proud to care for patients living in South Buckinghamshire for over 30 years and we welcome the added clarity from Buckinghamshire, Oxfordshire and West Berkshire (BOB) Commissioners that our new formal agreement provides. This role for Thames Hospice as lead palliative care provider ensures continuity of care and patient experience across Wexham Park Hospital (WPH), and our Inpatient and Hospice at Home services.

Bruce Montgomery Trustee and Chair, Patient Care and Quality Committee Loren Broughton Director of Nursing

As well as this planned expansion, we have also seen a continued increase in activity within our established population in East Berkshire. This reflects the rising need to deliver palliative and end-of-life care delivered to an increasingly complex group of patients who are living longer with advanced life-limiting illnesses.

This trend is also reflected in our Inpatient Services (IPS) where we have cared for more acutely dying patients admitted directly from hospital. WPH is now the primary source of inpatient admissions for specialist palliative and end-of-life care. We are supporting more people to remain in their homes, bringing our clinical expertise to them in their preferred place of care. We have completed a two-year pilot of our five-bed specialist palliative Virtual Ward and secured a dual funding model with a financial contribution from the NHS, supplemented with a charitable grant to continue this. A service evaluation of the pilot was presented at the Association for Palliative Medicine annual conference in March 2025, and we plan to publish the results of an ethically approved research study, which explored patient experience of care on our Virtual Ward.

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We have improved our staffing models to ensure that we deliver high quality, agile patient care. Underpinning this is a framework to ensure patient safety across our clinical services and support services. A new monthly compliance and quality meeting brings together leaders from clinical and non-clinical departments to share learning. The meeting includes trend analysis and learning from incidents, review of outcomes from mortality review meetings, oversight of health and safety around our Hospice and regular spotlights on the contribution that different teams make in supporting our patients.

Looking to the year ahead, we will work more closely with system partners across primary and secondary care, helping to support the movement of care out of hospitals and into community settings closer to home. We plan to align our new compliance and quality structure proportionately with the Patient Safety Incident Response Framework (PSIRF) - with a particular focus on human factors and learning from incidents. We are also embarking on an ambitious and exciting process of digital transformation, which will harness the power of IT and technology to help our people thrive in their roles and support them to focus on the provision of holistic patient care.

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2 Our Children and Families team supporting a group of young people

Part two

Review of quality performance 2024/2025 Quality governance provides a framework for organisations and individuals to ensure the delivery of safe, effective and high quality healthcare. Its purpose is to help organisations, like hospices, and their staff, monitor and improve standards of care.

Thames Hospice is regulated by the Care Quality Commission (CQC). We work closely with them to ensure our services provide people with safe, effective, compassionate and high-quality care, underpinned by continuous quality improvement. We continue to monitor ourselves against the five key questions asked of us by CQC: Safe – are patients protected from abuse and avoidable harm?

Effective – does our care and treatment achieve good outcomes and promote good quality of life and is evidence based, where possible?

Caring – are patients involved and treated with compassion, kindness, dignity and respect?

Responsive – are services organised to meet patients’ needs?

Well-led – does the leadership, management and governance assure the delivery of high-quality patientcentred care, support learning and innovation and promote an open and fair culture?

Alongside the five key questions, we are also implementing initiatives to measure our performance within the quality statements outlined in the new CQC assessment framework. We are committed to seeking and acting upon feedback provided to us and are dedicated to ensuring our patients’ and their loved ones’ experiences and thoughts are heard.

At Thames Hospice there are several quality governance functions: patient relations; patient safety; health and safety; patient clinical audit and effectiveness, incidents and risk monitoring, policy and quality improvement.

Collectively, we work together to ensure our patients receive safe, effective and caring treatment under the umbrella ‘quality’.

Caring for our community in 2024/2025 Hospice at Home

26,525

We cared for

visits and calls from our 24/7 Response Team to patients at home

Our Virtual Ward Team

Inpatient Services

98% referrals contacted within 24 hrs

336 patients

on our Inpatient Unit

93% admitted within 3 days of referral

Counselling, Pastoral and Bereavement Support

2,487

Our Pastoral Care Team provided

Counselling sessions

2,823

sessions with patients and loved ones

were held by the Counselling and Bereavement Team

Supportive sessions 1,647 held by our Children and Families Team

cared for

132

patients

and made

505 visits

10

Our Care Team made 8,232 visits

to 231 patients

Hospice Outpatient Services

2,382

934

provided by our Hospice Outpatients Team

provided by our Complementary Therapy Team

days of care

Treatments

1,615

Lymphoedema appointments took place

944

Physiotherapy

sessions took place

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Thames Hospice facts and figures We present data from 2022/2023 onwards as this is a reflection of usual practice in the post pandemic era, and is consistent with clinical and cultural changes across the Hospice from 2022 onwards.

Commissioning of hospice care services to South Bucks Primary Care Network (PCN) Since January 2025, Thames Hospice is delighted to have been commissioned as lead provider for all community and inpatient care services to the South Bucks PCN.

Care Team Launched in January 2022, our Health Care Assistants offer compassionate support and personal care to people in their own homes who are in the last six weeks of life.

No of visits made

Hospice at Home In 2024/2025, the majority of patients we supported received care in their own homes, helping them manage the impact of their illness and remain comfortable in their own surroundings.

Our Hospice at Home team provide specialist palliative and end-of-life care to patients who wish to die at home, ensuring they can do so with dignity and peace.

disciplinary clinical team delivers compassionate, timely, and coordinated support.

This joined-up care includes skilled communication, assessment, symptom control, nursing interventions, tailored personal care, provision of information about the dying process, and dignified care and support before and after death.

Working closely with families and our local healthcare partners—including GPs and District Nurses—our multi-

2022/2023

2023/2024

2024/2025

3,808

9,774

8,232

Virtual Ward Launched on 1 December 2022, our Virtual Ward is a consultant-led service developed in conjunction with the Frimley Integrated Care Board (ICB) and is available to patients within the Frimley ICB geographical area.

2022/2023*

2023/2024

2024/2025

Number of admissions

28

114

132

Number of discharges

26

108

122

*Four months activity December 2022 – March 2023

24/7 Response Service and Advice Line The Response Team is a multi-disciplinary team comprising Clinical Nurse Specialists, Paramedic Specialists, Senior Staff Nurses, Health Care Assistants and Doctors.

2022/2023

No of patients on caseload

Number visited or telephone consultation

12

1,225

24,721

2023/2024

1,185

24,250

Medical Team Following the closure of eight beds on our Inpatient Unit in 2022, our Doctors and Nurse Consultant started seeing patients in their own homes, in clinic and those accessing Outpatient Services at the Hospice. Medical activity is also reflected in the care of patients on the Virtual Ward.

2024/2025 2022/2023

2023/2024

2024/2025

No of patients

76

81

70

No of visits

81

65

138

1,240

26,525

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Hospice Outpatient Services

Inpatient Services The multi-disciplinary team working on our Inpatient Services provide specialist symptom control, complex palliative and end-of-life care to patients, together with support for their families.

2022/2023*

2023/2024

2024/2025

Total admissions

360

322

336

Average occupancy

88%

90%

84%

47

32

26

(13%)

(10%)

(8%)

328

291

306

(87%)

(90%)

(92%)

20.72

18.85

15.26

Our Outpatient Services, delivered within the Paul Bevan Wellbeing Centre, support patients with life-limiting illnesses to remain independent whilst introducing the role for hospice support alongside other clinical services. This service has been reviewed to ensure we continue to widen reach and improve access for more patients within our community, and we launched our refreshed outpatient programme in April 2025.

Six-week outpatients programme 2022/2023

2023/2024

2024/2025

No of Patients

199

189

147

No of Attendances

2,464

2,846

2,382

2022/2023

2023/2024

2024/2025

No of patients

443

391

324

No of treatments

1,442

1,263

934

2022/2023

2023/2024

2024/2025

No of patients

262

169

170

No of treatments

1,872

1,099

944

Discharges

Complementary therapy

Patient deaths

Average length of stay (in days)

*We closed 8 beds in September 2022.

Expansion of our community offer to include Virtual Ward beds means we are supporting more patients to remain at home which impacts on total inpatient admissions. Despite this shift, occupancy remained stable and the inpatient death rate has risen to 92%, reflecting the increasing clinical complexity of patients who need specialist inpatient care at the end of life.

Physiotherapy

Lymphoedema services We were pleased that our contract to provide this essential support to patients living with lymphoedema has been renewed this year.

2022/2023

2023/2024

2024/2025*

No of patients

455

470

466

No of treatments

1,865

2,158

1,615

*In 2024/2025 our lymphoedema team stopped offering non-NHS appointments for complementary lymphatic drainage.

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Training and development at Thames Hospice

Counselling, Pastoral and Bereavement Support This service, delivered by counsellors, pastoral care workers, children’s social workers, chaplain, and children’s support staff, underpins our three clinical areas in the provision of holistic, person-focussed care.

Counselling 2022/2023

2023/2024

2024/2025*

No of clients

482

440

324

No of sessions

5,654

4,793

2,487

* Lower numbers in 2024/2025 reflect the cessation of our post-covid Co-Connect programme in March 2024.

Pastoral care

Training is an essential part of our commitment to staff for professional development and safe clinical care for patients. In 2024/2025, we had a continued emphasis on end-of-life care training and we expanded our core training for our clinical professionals.

All patient-facing staff received clinical refresher training to bring them up to date with evidence-based practice.

380 professionals

The training and development of local healthcare professionals also continues to be a strong focus of our work, with teaching content tailored to local professional needs and clinical practice.

Local care homes

Learnt with CARE

We delivered over

300 training courses We offered free training to

We delivered for our staff

Learning for Work Week

Additional Quality Indicators Complaints

No of patients/family members

No of sessions/ interventions

2022/2023

2023/2024

2024/2025

1,508

1,663

1,971

3,479

3,275

2,823

Counselling for children and young people

16

2022/2023

2023/2024

2024/2025

No of clients

340

238

264

No of family visits

727

1,672

1,647

In 2024/2025, we received eight clinical complaints. Key themes included concerns about communication and time taken to achieve stable symptom control. In each case our senior staff worked with the person making the complaint to understand and resolve issues as quickly as possible.

At Thames Hospice, we are determined that any issue raised by staff, patients, clients, family, friends, carers or visitors is responded to immediately and in person, and that the observations made are listened to. Our policy is that following investigation, immediate changes are made where required to working policies and processes.

Furthermore, our staff are immediately advised of any changes needed. Our view is that communication can always be improved and we will continually strive for this.

We continue to use the outcomes and learning gained from any issues raised to improve service provision. Potential issues are routinely reported to our Patient Care and Quality Committee. Significant issues are reported to our Board, the Care Quality Commission (by exception if very high risk) and our NHS Commissioners, as part of our quality reporting processes.

Accolades We receive some incredibly positive feedback from patients and their families. And we receive a large number of accolades across all our services. Some extracts from these accolades can be found on page 18.

In 2024/2025 we also gathered feedback using iPads at our reception desks. This system enables everyone using any of our services to give immediate feedback.

Analysis of this feedback showed an overall score of 100% Excellent or Good in 2024/2025 We also record the many thank you cards and letters that we receive each month across all our services.

Reporting and review of feedback received The views and experiences of patients and their families are very important to us and enable us to look at how we can learn, develop and improve the services we provide.

Feedback is reported quarterly at the Patient Care and Quality Committee. We are often very privileged to relay a patient or family member’s experiences of the Hospice.

We find this very thought-provoking and supportive of core service decision making throughout the organisation.

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2 I am so grateful to the Hospice for my bereavement counselling. I have taken on board everything that you have discussed with me, and I cannot tell you how much it has helped. I feel I am mentally in a better place to help both myself and my children with our grief.

Thank you for all the wonderful work that you do and the smiles that each and every one of you carry with you as you do your jobs. You have the kindest hearts and it is clear that the patients and their families are your priority. Thank you for all of the care and support.

The service you provide is fantastic. In people’s hour of need you were always here. Indeed, in my hour of need you were there. I can’t thank all the nurses enough who came out in the middle of the night to give my loved one comfort and support.

What our patients and their families say about our services

You all do such an amazing job and work tirelessly hard.

Your warm smiles and friendly chats brightened up our days.

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Clinical accidents and incidents We use Vantage, an online incident reporting system.

This gives us a streamlined incident reporting process and enables us to produce in depth reports for governance monitoring. Vantage is used throughout the organisation and is mandated as the standard reporting tool for all staff. The Executive Team and relevant team leaders are automatically notified of any incidents. All reported incidents are reviewed at a monthly compliance and quality meeting that colleagues from across the Hospice attend. Our Patient Care and Quality Committee

Type

Pressure ulcer – inherited

Pressure ulcer – acquired

Number in years

93

44

335 (365 in 2023/2024) clinical incidents and accidents were reported and investigated during 2024/2025, with 162 of them reported ‘for the record’ only or as ‘near misses’.

Some incidents were reported by us to other organisations as they were incidents our staff had found and reported, but were not our incidents, or were for the record only. The table below summarises clinical incidents that we investigated.

Seriousness impact

Actions

Medium

Due to the ongoing deteriorating nature of their condition, patients were admitted with established pressure ulcers. We have procedures that we implement to care for these patients, including special mattresses and turning plans.

Medium

The progression of disease in some of our patients meant that low-grade pressure ulcers formed. We implement a range of interventions to minimise this risk where at all possible and also learn from cases to improve future care.

Clinical staff involved undertook reflective reviews, and learnings were shared with all clinical staff. Trend analysis also helps us identify any recurrent themes for targeted training.

Drug incidents

58

Various

Patient slips, trips and falls

26

Various

In most incidents our patient was unharmed.

Patient safety and care

13

Various

In most incidents our patient was unharmed.

Information governance

5

Low

Minor incidents; promptly resolved.

Infection control We thank you with all our hearts for the wonderful and compassionate care you gave. Nothing was too much for your team.

We felt comforted knowing how well our loved one was being looked after by you all, and grateful for having such a wonderful space to share in their last few days.

receives and reviews a quarterly report on all clinical incidents that are reported.

Each drug incident was investigated.

Our visits were made easier knowing we were in safe hands. Our loved one always looked calm, comfortable and peaceful.

You supported us all and made a very sad, difficult time a bit more bearable. Thames Hospice is a very special place, and you all do amazing work there.

Patient safety summary

In 2024/2025 there were no cases of patients with a new diagnosis of Clostridium Difficile infection or a blood stream MRSA infection. No vomiting and diarrhoea outbreaks took place at the Hospice over this period. We carried out regular infection control audits in 2024/2025 and no infection control incidents were reported.

Electronic patient records system EMIS We use EMIS, an electronic patient record system. This enables the sharing of patient data with our local GPs and some community partners, resulting in better co-ordinated care and treatment, and increased responsiveness as information is shared more quickly and efficiently.

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Significant audits Hospice UK benchmarking results Hospice UK has developed a benchmarking tool for hospices – the Inpatient Quality Metrics. These record benchmarking data on falls, pressure ulcers and medication incidents. The data indicates that our bed occupancy levels are consistently well above average, meaning that we have helped as many people as possible without compromising patient care. We are proud that overall our results compare very favourably with those of other hospices.

In 2024/2025: • Our inpatient beds have been 84% occupied.

• The number of falls per 1,000 bed days was on average below those reported by other hospices.

• We reported no serious medication incidents.

FAMCARE audit The 2024 independent FAMCARE Audit was undertaken during summer 2024. This year 22 specialist palliative care inpatient units, including Thames Hospice, took part in the survey. This is an annual audit measuring family and carer satisfaction with our services, and focuses on communication, support and symptom management. Taking part in FAMCARE enables us to identify our strengths, to address concerns, and to improve the quality of our services. In addition, it ensures that families feel heard and it supports our commitment to compassionate, responsive service.

We sent FAMCARE surveys to the next of kin of people who had died at Thames Hospice in our Inpatient Services between 1 June and 31 August 2024. It was our eighth year participating in the FAMCARE Audit.

Nurse Sue with Marjorie

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2 Internal audit and monitoring results To ensure that we are continually meeting standards and providing a consistently high quality of service, Thames Hospice has an audit and monitoring programme in place.

This enables us to monitor our services in a systematic way, identifying areas for audit and evaluation in the coming year.

Our focus is on quality and benchmarking of services, patient safety, good record-keeping, infection control standards and legislation compliance. Our audits create a framework where we can review information and identify where we can make improvements.

Safe

Effective

Regular Patient Care and Quality Committee meetings provide a forum to monitor quality of care and to discuss quality and audit evaluation results.

The Thames Hospice Audit Plan 2024/2025 identified audits against the five key lines of enquiry as set by the Care Quality Commission; some examples from our 2024/2025 clinical audit plan are detailed below.

Audit/ monitoring

Detail and outcome of audits

Falls audit

The monthly falls audit looks at falls in our Inpatient Unit and helps to identify any areas for learning. The audit is completed by the Ward Sisters or Inpatient Services Manager, with any learnings communicated to the team. Examples of learnings have been the importance of a timely review of risk assessments and the regular checking of sensor mats in use for any faults.

Controlled drug audit and CDAO audit

The quarterly controlled drug audit and annual CDAO audits are undertaken to ensure the safe and lawful management of controlled drugs. As part of the audit process, drug registers are reviewed, stock levels verified, and staff practices observed to ensure full compliance. Any discrepancies or areas for improvement are addressed through immediate action, including staff training, process refinement, or policy revision. These audits reinforce a culture of safety, accountability, and clinical excellence in the use of medicines that support essential comfort and symptom control for our patients.

Fire risk audit

The annual fire risk audit is essential to proactively identify and mitigate potential fire hazards and complies with the Regulatory Reform (Fire Safety) Order, and ensures we have a proactive and preventative culture. All actions from the audit are added to the action plan and addressed in a timely fashion, with collaboration across departments.

Patient demographic audit

The patient demographic audit gives insight into the characteristics of the population served, including age, gender and ethnicity. It provides the Hospice with valuable information to ensure that we offer an equitable service that is accessible and is tailored to the needs of the local community.

Antimicrobial audit

22

Caring

The antimicrobial audit enables monitoring of prescribing patterns, preventing overuse or misuse of antimicrobial medications. The audit supports best practice in medication management, thus enhancing patient safety, and aligning with our regulatory obligations.

Responsive

Well-led

Care after death audit

The care after death audit ensures that all procedures following a patient's death are carried out with dignity, sensitivity and in line with our policy. Results of the audit are communicated with family, staff and stakeholders. It identifies areas for improvement, supporting the Hospice’s continuous service improvement strategies.

ReSPECT audit

The ReSPECT audit checks that the ReSPECT documentation records a patient’s wishes and clinical decisions about any emergency care are clearly recorded and regularly reviewed. This helps us ensure that we uphold and support patient autonomy, and shared decision making, and therefore that, where possible, care aligns with individual preferences and clinical needs. Outcomes of these audits are discussed at compliance meetings and shared with the clinical teams to promote continuous improvement.

Morbidity and mortality review

The monthly morbidity and mortality review allows a critical review and evaluation of patient safety and clinical outcomes. This enables the identification of what went well, and areas for improvement, with the shared learning across teams, promoting a culture of continuous improvement and enhanced clinical practice.

Call bell audit

We undertake regular call bell audits, which helps us to identify and address issues that could compromise patient safety. This could include unresponsive systems or inaccessible call points, and any delays in answering patient call bells. Areas where delays are found are investigated, addressed and highlighted to leadership teams, therefore ensuring patient safety, satisfaction and confidence in the service provided.

Patient safety bulletin

Completed quarterly, this bulletin to all clinical staff highlights important safety issues, incidents and lessons learned – thus keeping staff informed about potential risks, best practices, and safety protocols. By sharing timely updates and promoting safety initiatives, the bulletin supports high quality patient care standards.

Patient bereavement survey

The patient bereavement survey collates feedback from families and loved ones of their experience of our Inpatient Services. Sharing the outcome of this survey, reinforces best practice, enables review of any areas for improvement and informs ongoing service improvement. It helps us to ensure that the care we provide continues to meet the needs and expectations for those we serve.

DBS audit

The DBS audit helps us ensure that we maintain a safe environment, with appropriate staff and volunteers who have up to date background checks, thus supporting a culture of safety, accountability and trust amongst staff, stakeholders, and patients.

Data flow mapping audit

The annual data flow mapping audit investigates how operational data is collected, stored, processed and shared in line with data protection regulations, and highlights any potential risks and vulnerability, ensuring effective management transparency, and that privacy and confidentiality are always upheld.

Clinical compliance and quality meeting

Monthly compliance and quality meetings—covering both clinical and non-clinical areas—are held to ensure that leaders and staff regularly review practices, policies, and regulatory requirements, maintaining the highest standards of care. These meetings allow teams to discuss audit findings, address areas for improvement and foster a culture of learning through continuous improvement which helps us to enhance patient outcomes, and staff retention and wellbeing.

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2 Colleagues from our Housekeeping Team

Other audit results

Duty of candour

In 2024/2025, we completed a submission against the NHS Data Security and Protection Toolkit. The Data Security and Protection Toolkit is an online self-assessment tool that allows organisations to measure their performance against the National Data Guardian’s ten data security standards. All organisations that have access to NHS patient data and systems must use this toolkit to provide assurance that they are practising good data security and that personal information is handled correctly. As in previous years we were one of the very first hospices in the country to complete a submission, and we are pleased that it was compliant with all NHS standards for information management, confidentiality, data protection assurance, information security, clinical information and records holding.

Thames Hospice promotes a culture that encourages candour, openness and honesty at all levels of the organisation. We have a culture of safety and a commitment to transparency that permeates everything we do.

Regulatory inspection Thames Hospice was inspected by the Care Quality Commission (CQC) in August 2021. Staff and volunteers at Thames Hospice had much to celebrate after receiving an ‘outstanding’ rating following the inspection. The inspection outlined how we were meeting the CQC national standards.

The Hospice is not subject to any special reviews under section 48 of the Health and Social Care Act 2008.

Under the new CQC inspection regime, hospices are subjected to the same level of scrutiny as hospitals, making this ‘outstanding’ rating incredibly special. The CQC found that Thames Hospice is outstanding in responding to people’s needs, treating families with dignity, kindness and respect and being well-led.

To access a full copy of this and past reports, please go to www.cqc.org.uk/location/1-9676860611 or visit our website at www.thameshospice.org.uk where there is a link to the report at the bottom of our homepage.

In 2024/2025 we continued to work with our assigned CQC inspector. We ensure that the CQC are informed of any significant clinical developments at the Hospice.

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The duty of candour is a legal duty to be open and honest with patients and their families when mistakes in care have led to significant harm. It applies to all health and social care organisations registered with the regulator, the CQC. We recognise that the promotion of a culture of openness and transparency is essential to improving and maintaining patient safety.

Our duty of candour policy provides guidance to clinical employees about the principles of being open and duty of candour, and sets out the processes to be followed to support openness with patients and their families following a serious safety incident. In addition the accident and incidents reporting policy provides a clear and transparent process for the management of clinical incidents, including reporting. All incidents are discussed at the monthly accident and incident review panel and are also reported to relevant trustee committees and Board.

Speaking up at Thames Hospice We encourage speaking up across our Hospice. Staff are encouraged to confidentially raise any issue or concern through a number of routes. Our hope is that staff will always feel able to approach their managers should they have any concerns; and with our ‘Peoples’ Voice’ sessions we have an active staff forum where issues are often raised.

We also have an independent Freedom to Speak Up Guardian, supported by Freedom to Speak Up Champions from across the organisation. One of our Trustees is also our Freedom to Speak Up Trustee, and all our Trustees have made their contact details freely available to staff should they wish to raise an issue and want to speak to a Trustee.

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Part three

Update on last year’s pledges How will priority be achieved?

How will progress be monitored & reported?

We will provide agile, responsive care and support for our patients and their loved ones in their preferred place of care

Collaborative working with hospice teams and our healthcare partners across the community to deliver responsive care. Develop our data capture and reporting to evaluate and guide service delivery.

Feedback from multidisciplinary team meetings. Creation of patient-focussed outcome measures which will be reviewed alongside patient and family feedback.

Weekly and monthly trends analysis will be reviewed at quarterly clinical committee meetings and Board meetings.

We have developed a suite of metrics which monitor clinical performance across our services. These are reviewed monthly to shape service delivery and discussed quarterly at our patient care and quality committee and with our commissioners.

We will provide excellent standards of care within financially sustainable models

Clinical leaders will be trained and supported to develop detailed understanding of charitable funding and budget management.

Clinical budgets will be set within clear financial frameworks and monitored with monthly review and forecasting. Oversight will be provided at the finance and income generation committee.

Investment and development of our Finance Team has supported partnership working with clinical leaders to enhance efficient management of costs whilst ensuring safe care standards are met.

We will ensure our clinical services offer choice and are delivered safely to achieve the optimum experience for our patients and their loved ones

Empowerment of our clinical leaders to offer choice across safe clinical settings. Create a culture and system for learning which has patient experience at its core.

Review patient experience across our range of services including transparent review of incidents, lessons learned and trends analysis as part of robust compliance and quality monitoring.

Learning culture and robust clinical governance has been embedded across the Hospice through the compliance and quality meetings.

We will facilitate choice by reaching patients earlier in their disease trajectory and support earlier care planning

Advocate for palliative care services and tell our story to our local population.

Use our Outpatient Services to introduce patients and families to the Hospice earlier.

Analysis of referral rates to our Outpatient Services and review of outcomes from outpatient care.

The model of care delivered by our Outpatient Services has been redesigned in 2024/2025 and the new structure was launched in April 2025.

Priority action

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Outcome

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Part four

Priorities for 2025/2026 In November 2024, we launched our refreshed strategy which sets out our ambitious plans and key priorities for the next three years.

Underpinning this strategy are a suite of measures which shape our clinical focus for 2025/2026.

Key clinical priorities for the next year Strategic priority

What

How

Care with agility

Coordinate care across our clinical services and with our partners.

Review our use of the EMIS electronic patient record system to optimise recording of patient information, coordinate information sharing and improve data analysis.

Support and develop a resilient clinical workforce.

Review the team structure and staffing for our Hospice at Home service to address the demands of increased activity.

Clinical supervision training for Inpatient Services.

Extending reach

Underpin clinical care with continuous quality monitoring and improvement.

Align our new compliance and quality structure proportionately with the patient safety incident response framework with a particular focus on human factors and learning from incidents.

Improve multi-disciplinary team partnership working within the population we serve.

Develop close partnership working with paramedic and clinical specialist hospice teams to enhance shared decision making and support hospital avoidance.

Colleagues Toggy and Carmen from our Pastoral Care Team

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Part five

Statements of assurance from the Board of Trustees Our Trustees are committed to the Hospice’s quality agenda.

Our governance structure is extremely thorough, robust and well-established and all our Trustees play an active role in supporting the Hospice, and ensuring that all our services are of the quality that we have promised to our stakeholders.

Chris Aitken (Chair)

Frances Lawrence

During 2024/2025, we supported local NHS commissioning priorities by providing palliative and end-of-life care across key services: Inpatient Services

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Hospice at Home

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Outpatient Services

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Lymphoedema Services

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Counselling, Pastoral and Bereavement Support

Alice Hunt

Jon Toohey

In addition, we provide a comprehensive range of education, training and support for external healthcare professionals such as care home staff, community nurses and GPs. The income provided by the NHS represented approximately 30% of the total income generated by Thames Hospice in the reporting period 2024/2025. The balance of our expenditure on charitable activities was raised through the generous support of our community, including legacies and fundraising, as well as income generated from our retail activities and our investments.

Judith Kinder

Inpatient beds for complex palliative and end-of-life care usually for up to two weeks stay.

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Intermediate care beds for patients approaching the end of life with an estimated prognosis of six weeks.

Nancy Barber

Proactive and responsive clinical support Our multi-disciplinary team of Clinical Nurse and Paramedic Specialists, Senior Staff Nurses, Doctors and Health Care Assistants deliver 24/7 comprehensive palliative and endof-life care services for patients with complex needs in their place of residence.

Virtual Ward Our Virtual Ward is available to patients within the Frimley Integrated Care Board geographical area. It provides medically-led care for acutely symptomatic patients in the final stages of life in their own homes. The Medical Team is supported by Clinical Nurse Specialists, Paramedic Specialists and Health Care Assistants in the delivery of this service.

Care Team We offer Health Care Assistant-led compassionate support and personal care to people with a palliative diagnosis in their own homes who are in the last six weeks of life.

24-hour telephone advice line We provide a 24-hour palliative and end-of-life care telephone service to give advice to people with palliative care needs and their families, as well as to healthcare professionals who need guidance and support on delivering palliative care. The team is available 24/7, 365 days a year, to provide guidance on symptom control, practical advice and emotional support.

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Senior Nurse Annie with Louise

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Symptom management for patients with complex palliative physical, psychological, social or spiritual symptoms which cannot be managed by generalist services or specialist community services. Our services include:

Review of services

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Symptom management for patients with complex palliative physical, psychological, social or spiritual symptoms which cannot be managed by generalist services or specialist community services. This may include:

Hospice at Home

The following are statements all providers are required to include in their Quality Account. Because we are an independent charity providing palliative care, not all of these statements are directly applicable to Thames Hospice.

We are a core provider of complex, specialist palliative and end-of-life care to adults over the age of 16 years. Our care is delivered at the Hospice and in patients’ usual place of residence.

Inpatient Services

Bruce Montgomery

Our Board of Trustees

Colleagues from our Hospice at Home Care Team

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Physiotherapist Iulian with Ali in our Rehabilitation Suite

Counselling, Pastoral and Bereavement Support Our Counselling Team provides emotional support for patients and families up to and following bereavement, which includes counselling for children and young people.

Our Counselling Support Services are delivered by qualified counsellors, trained bereavement support volunteers and is further supported by the Pastoral Care team.

Participation in National Clinical Audits Thames Hospice is not part of the NHS and currently has not participated in national clinical audits or national confidential enquiries.

Outpatient Services (delivered in our Paul Bevan Wellbeing Centre) Six-week outpatients programme We help patients diagnosed with a life-limiting condition remain independent by supporting them through tailored programmes of wellbeing and therapeutic care within our Paul Bevan Wellbeing Centre at the Hospice.

Complementary therapy The Complementary Therapy Team offers a variety of therapeutic treatments for patients and carers (also available for patients staying on our Inpatient Unit). Therapies include massage, reflexology, Reiki, aromatherapy, visualisation techniques and therapeutic touch.

Lymphoedema service This is a nurse-led service for people with primary Lymphoedema or as a result of cancer and its treatments.

Research Thames Hospice, in conjunction with the University of Cardiff, supported an ethically approved research study exploring patient experience on our Virtual Ward. Research governance was led by the University of Cardiff and monitored locally via the Thames Hospice Patient Care and Quality Committee.

Completeness of Data Submitted to the Secondary Uses Service (SUS) As a specialist palliative and end-of-life care provider that is not part of the NHS we do not submit data to SUS because we are not eligible to participate in this scheme.

Use of CQUIN Payment Framework The Hospice’s income during 2024 - 2025 was not conditional on achieving quality improvement through the Commissioning for Quality and Innovation (CQUIN) payment framework because it was not eligible to participate in this scheme as a third sector organisation. We are required to record the number of patients seen in the community setting.

Physiotherapy Our Specialist Palliative Physiotherapists play a key role in improving our patients’ quality of life, helping to optimise their mobility and wellbeing, to live as independently and fully as possible.

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Our vision Quality of life to the end of life, for everyone.

Our purpose To provide complex, specialist palliative and end-of-life care to local people facing a life-limiting diagnosis, giving them dignity, comfort and the best possible quality of life in their preferred place of care.

Our values

C

Compassion

A

Ambition

R

Respect

E

Excellence

Compassion for everyone in a safe, caring environment.

The desire and determination to serve everyone in our community.

Respect for everyone’s dignity.

Committed to excellence in everything we do.

Call 01753 842121 Visit www.thameshospice.org.uk Windsor Road, Maidenhead, SL6 2DN Registered charity number 1108298